| BackgroundWith the rapid development and progress of endovascular technology,thoracic Endovascular Aortic Repair(TEVAR)has gradually become a first-line treatment for the descending thoracic aortic disease(DTAD),but there have been many new challenges,one of which is the branch reservation of the aortic arch.The primary lesions of approximately 40%of patients with DTAD are very close to the left subclavian artery,then the left subclavian artery has to be covered to complete the TEVAR.Covering the left subclavian artery will bring additional risks,including cerebral ischemia(such as cerebral infarction,transient ischemic attack,reversible ischemic neurological dysfunction,etc.),spinal cord ischemic(such as paraplegia)and left Upper limb ischemia.However,the results reported by different authors are not the same due to the different research groups and different diagnosis of the disease.The role of revascularization for the left subclavian artery coverage during TEVAR is mainly based on two factors:benefit and risk.The current results of the revascularization study are basically in the area of open surgical technology,including carotid artery-left subclavian artery bypass,left subclavian artery transplantation and so on.The role of endovascular revascularization technology,such as the chimney stent technology/in vitro fenestration technology/in vivo fenestration technology were not clearly stated,as the same as the difference between the different endovascular revascularization technologies.Objectives1 To observe and analyze the effect of the left subclavian artery coverage and reconstruction on the clinical outcome during the TEVAR of DTAD.2 To observe and analyze the application and clinical results of different envascular reconstruction techniques in TEVAR of DTAD.MethodThis retrospective study selected patients with DTAD receiving TEVAR from December 2014 to June 2017,diagnosis of the DTAD depends on the computed tomography angiography(CTA),The primary lesion location,the proximal aortic diameter of descending thoracic aortic lesions,the diameters of bilateral vertebral artery,the aortic maximum diameter were also recorded from the CTA images.All patients received conservative treatments and TEVAR treatment,with or without left subclavian artery revascularization.Follow-up with CT scan was conducted one month,6 months,12 months,and yearly after TEVAR.Statistical analysis was conducted using SPSS 21.0(IBM,USA)software.Results General characteristics262 patients with DTAD were involved in the retrospective study,including 193 males and 69 females.There were 156 patients in the uncovered group(UCD group),27 patients in covered without revascularization group(COR group),79 patients in covered with revascularization group(CWR group).The mean age in the UCD group(59.92 ±12.45 vs 55.82)were significantly bigger than that of the CWR group.The male percentage(84.81%vs 68.59%vs 70.37%)in the CWR group were significantly bigger than that in the other two groups.The mean diameter of the left vertebral artery(3.80 ±0.89 vs 3.03 ± 0.69)in CWR group were significantly bigger than the mean diameter in the right vertebral artery of the CWR group.P values of the above were all less than 0.05 with statistical significance.Treatment and early resultsAll the 262 patients received TEVAR,the technical success rate is 100%;79 patients received left subclavian artery revascularization,the technical success rate is 93.67%.There were 19 major complications,7 re-operations and 3 deaths within 30 days after TEVAR treatment.The mean operation time(161.32±59.31 vs 71.55±28.83 vs 76.67±29.54)of CWR group were bigger than that in the other two groups.The diameter(33.00±3.46 vs 35.04±3.86 vs 34.43±3.60)and length(171.38±31.52 vs 188.04±18.75 vs 184.29±31.48)of the stent-graft in the UCD group were smaller than that of the other two groups.The postoperative hospital stay(7.93±6.4 vs 5.66±1.9 vs 6.00±2.05)of the COR group were bigger than that in the other groups.The incidence of cerebral ischemic events(11.11%vs 0%vs 1.26%)and the total events(major complications + death)(29.63%vs 5.13%vs 7.59%)in the COR group were bigger than that of the other two groups.P values of the above were all less than 0.05 with statistical significance.Follow-up resultsThe mean follow-up time was 534.45 days with extent of 48 to 973 days.There were another 8 re-operations and 21 deaths during the follow-up.There was no significant difference between three groups.The mean post-operative diameter of right vertebral artery(4.34±0.56 vs 3.07±0.76 vs 2.96±0.64)in the COR group were bigger than that of the other two groups.The mean post-operative diameter of right vertebral artery(4.34±0.56 vs 3.62±0.61)in the COR group were bigger than the mean pre-operative diameter of right vertebral artery in the COR group.P values of the above were all less than 0.05 with statistical significance.Survival analysisThe 1-year overall cumulative survival rate was 94.87%in UCD group,92.60%in COR group and 96.20%in CWR group.2-year overall cumulative survival rate was 90.38%in UCD group,88.89%in COR group and 93.67%in CWR group.There was no significant difference between three groups.The risk factor influencing overall survival was:age(older than 65 years).The risk factors influencing cerebral ischemic events within 30 days after TEVAR treatment were:the history of cerebrovascular disease and coverage of left subclavian artery.General characteristics of endovascular revascularization research76 patients with DTADwereinvolved in the retrospective study,including 65 males and 11 females.There were39 patients in thechimney stent group,lOpatients in the in vitro fenestrationgroup,27patients in vivo fenestration group.The pre-operative diameter of left vertebral artery(2.88±1.25 vs 3.96±0.82 vs 3.82±0.54)and the percentage of left vertebral artery dominance(40.00%vs 80.05%vs 85.19%)in the in vitro fenestrationgroup were smaller than that of the other two groups.P values of the above were all less than 0.05 with statistical significance.Operations and early results of endovascular revascularizationAll the 76 patients received TEVAR with left subclavian artery revascularization,the total technical success rate is 93.42%.The technical success rateis 92.31%in the chimney stent group,100%in the in vitro fenestration group,92.59%in the vivo fenestration group.There were 6 major complications,2 re-operations and no deaths within 30 days after TEVAR treatment.The mean operation time(130.26±41.74 vs 199.30±74.87 vs 183.59±49.23)in the chimney stent group were bigger than that in the other groups,while the percentage of post-dilation(2.56%vs 70.00%vs 55.56%)in the chimney stent group were smaller than the other two groups.The percentage of pre-dilation(92.59%vs 0%vs 10%)in the vivo fenestration group were bigger than that in the other groups.The postoperative hospital stay(8.10±2.92 vs 5.56±1.29)in the the vivo fenestration group were bigger than that of the chimney stent group.P values of the above were all less than 0.05 with statistical significance.Follow-up results of endovascular revascularization researchThe mean follow-up time was 412.86 days with extent of 48 to 966 days.There were another 4 re-operations,5 deaths and 5 endoleak during the follow-up.There was no significant difference between three groups.Survival analysis of endovascular revascularization researchThe 2-year overall cumulative survival rate was 92.20%in chimney stent group,90.00%in the in vitro fenestration group and 95.70%in the vivo fenestration group.Conclusion1.The coverage of left subclavian artery during the TEVAR for the patients with DTAD will increase the incidence of cerebral ischemia events and upper limb ischemic events,and also extend the hospital stay after surgery.But it will not increase the incidence of spinal cord ischemic events.2.The coverage of left subclavian artery during the TEVAR for the patients with DTAD will increase the postoperative diameter of right vertebral artery.3.For patients with DTAD who need to cover the left subclavian artery during TEVAR,revascularization will significantly prolong the operation time,but it can reduce postoperative incidence of cerebral ischemic events and adverse events rate within the 30 day of the TEVAR.4.Both the coverage and the revascularization of the left subclavian artery do not affect the overall survival time after surgery.The risk factor that affect the overall survival time was:age>65 years;and the risk factors influencing cerebral ischemic events within 30 days after TEVAR treatment were:the history of cerebrovascular disease and coverage of left subclavian artery.5.Routine use of endovascularrevascularization techniques for TEVAR surgery after left subclavian artery coverage is safe and has a good technical,and will not affected by emergent/urgent surgery.6.Different endovascular revascularization techniques have their own advantages and disadvantages,the choice of different endovascular techniques for the revascularization does not affect the overall survival time of patients after TEVAR surgery. |
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